(PISR 001A)

The Republic of Palau
Palau International Ship Registry
“The Sea Lane to Prosperity” / THIS SPACE FOR OFFICIAL USE ONLY
OFFICIAL NO.
CALL SIGN

APPLICATION FOR REGISTRATION OF VESSEL, OFFICIAL NUMBER AND CALL SIGN

PART 1. TYPE AND DATE OF REGISTRATION please check as appropriate:

NORMAL
REGISTRATION
New Building / Transfer of Flag / Re-Registration
SPECIAL
REGISTRATION
Single Voyage / For Scrap / Sea Trial
PORT OF DEPARTURE
PORT OF ARRIVAL
BAREBOAT CHARTER
REGISTRATION
BBC IN
Registration / BBC OUT
Registration
Registration Date / yyyy / mm / dd / / /

PART 2. VESSEL PARTICULARS

PROPOSED NEW NAME AND SECOND PROPOSED NAME IN CASE FIRST ONE IS NOT AVAILABLE / IMO NUMBER / PREVIOUS NAME / PREVIOUS FLAG
VESSEL TYPE / YEAR BUILT / BUILDER/SHIPYARD / COUNTRY BUILT
HULL MATERIAL / DECKS / MASTS / CLASSIFICATION SOCIETY / DATE AND PLACE OF CONVERSION
LENGTH (M) / BREADTH (M) / DEPTH (M) / NET TONS / GROSS TONS / DEADWEIGHT / NO. OF ENGINES
ENGINE POWER (KW) / NUMBER AND TYPE OF ENGINES / ENGINE MAKER

PART 3. OWNER(S) AND BAREBOAT CHARTERER’S PARTICULARS

NAME OF OWNER(S) AND % OF OWNERSHIP / IMO NUMBER / RESIDENCE / TEL / FAX / EMAIL
(If more than two Owners , please attach extra sheet, signed and notarized) / TOTAL / 100%
NAME OF PROPOSED MANAGING COMPANY (if other than the owner) / IMO NUMBER / RESIDENCE / TEL / FAX / EMAIL
NAME OF CONTACT/DESIGNATED PERSON / EMAIL / TEL / FAX / POSITION
NAME OF BENEFICIAL OWNER / IMO NUMBER / RESIDENCE / TEL / FAX / EMAIL
NAME OF BAREBOAT CHARTERER / IMO NUMBER / RESIDENCE / TEL / FAX / EMAIL

PART 4. MORTGAGE

Mortgage to be recorded at vessel registration / please check as appropriate: / YES / or / NO / or / TBD

PART 5. CERTIFICATION

PRESENT CLASSIFICATION SOCIETY / PROPOSED NEW CLASSIFICATION SOCIETY (if different from present)
NEW CLASSIFICATION SOCIETY ISSUING ISM/ ISPS (if different from proposed new classification society)

PART 6. MANNING INFORMATION

TRADING AREA OF THE VESSEL (International, Restricted <600 nm, Coastal <200 nm)
INTERNATIONAL
RESTRICTED
SPECIFY THE PORT/AREA:
COASTAL
SPECIFY THE PORT/AREA:
VESSEL CERTIFIED FOR UNMANNED MACHNERY SPACE OPERATIONS:
YES NO ISSUED BY:___ / Operating Company Name: / IMO NUMBER:
(copy of Safety Management Certificate, shall be submitted if applicable along with the assessment for safety navigational form)
Proposed Manning:
(AS PRESCRIBED UNDER THE INTERNATIONAL CONVENTION ON STANDARDS OF TRAINING, CERTIFICATION AND WATCH KEEPING FOR SEAFARERS – AS AMENDED AND RESOLUTION A.1047(27) PRINCIPLE OF MINIMUM SAFE MANNING)
DECK / ENGINE
Capacity/regulation / Number of Persons / Capacity/regulation / Number of Persons
Master (II/2) / Chief Engineer (III/2)
Master (
I/3) / Chief Engineer (III/3)
Chief Mate (II/2) / Second Engineer (III/2)
Chief Mate (II/3) / Secon
Engineer (III/3)
Navigational Watch Officer (II/1) / Engineering Watch Officer (III/1)
Rating Forming Navigational Watch (II/4) / Rating Forming Engine Watch (III/4)
Deck Rating / Engine Rating
GMDSS OPERATOR:
OTHER:
SHIP SECURITY OFFICER
TANKER FAMILIARIZATION
PASSENGER VESSEL
COOK
ELECTRO – TECHNICAL

PART 7. CORRESPONDENCEAND BILLING AGENT

General Correspondence and Billing including annual tax invoices should be sent to the following address(s):

Full name and address of the responsible company(s) - (not an individual’s name)

1. General Correspondence:
2. Billing: / Telephone (1)
Telefax (1)
E-Mail (1)
Telephone (2)
Telefax (2)
e- Mail (2)

Note: If more than one billing agents, please attach extra sheet with detailed instructions as required.

PART 8. WAIVERS

Declaration and Affidavit of the need for waiver of The Republic of Palau Requirements with regards to Length and/or Age of the Vessel under respective Sections of Title 7 of the Palau National Code;

LENGTH–less than 7.62m Waiver of Section 702(a) / Under Section 702(c) / Check as appropriate / YES / or / N/A
AGE - above 20 years. Waiver of Section 702(b) / Under Section 702(c) / Check as appropriate / YES / or / N/A

The application for waiver(s) is made because the vessel does not meet requirements of Length and/or Age described in Title 7 of the Palau NationalCode, however the Owner desires to register under the Palau flag and declare that all other requirements to register the vessel will be met.

OATH OF DIRECTOR OF AN INCORPORATED COMPANY (APPLICANT OWNER) OR PERSON WHO HAD PROPER POWER OR ATTORNEY ON SIGNING THE APPLICATION AND AFFIRMATION REGARDING SURRENDER OF FOREIGN DOCUMENTS AND MAKING OF MARKINGS

I ___ a citizen of ______residing at _____ swear or affirm, as required by Section 708 of Title7 of the Palau National Code, that I ____am authorized bythe Article of incorporation as Director or byPower of Attorney__, to act on behalf of ship-owner or on behalf of the corporation organized and existing under the laws of ______, with offices at ______that said corporation is or will be Owner of the vessel named ______IMO Number ___, and that the name and residence of the Owner(s) or prospective Owner(s) and their respective citizenship(s) and proportion(s) of Ownership in the vessel is(are) as declared on the Application and that the present or prospective Master of the said vessel has been ordered or it will be ordered and instructed, upon receipt of the vessel’s Palauan Certificate of Registry and other Palauan Documents, to surrender the vessel previous documents deletion certificate issued by the Government of ______and to make the Vessel Markings required by Section 722 of Title7 of the Palau National Code.

I, acting as owner or owners’ representative hereby confirm that the Long Range Identification Tracking equipment (LRIT) must be installed and tested by one of the Authorized Services Provide (ASP)by Palau Administrationbefore the Safety Equipment Certificate is issued by the Recognized Organization on behalf of Palau flag.

______

NAME AND PASSPORT NUMBER

______

ADDDRESS AND CONTACT DETAILS

______

SIGNATURE

NOTE: This application cannot be signed by any other person other than the ship-owner, One of the Directors of the company listed in the Articles of incorporation or a third party that hold a proper notarized Power of Attorney acting on behalf of the ship-owner or Company registered as owner of the vessel.

ACKNOWLEDGEMENT

Subscribed and Sworn Before me

thisday of ______(Year)

at ______

Signature and Seal of Notary Public

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PISR FORM 001A REV 0.3